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WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # <br />0 WELL # <br />*Other: <br />COMMENTS /463A-itiPcIA/ ;14 <br />*DESTRUCTION (choose type below) <br />VER-BORE <br />s[], RESSURE GROUT <br /> Grout Specifications: /407 estr; <br />I L 1 444 "14 -7 e <br />WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <br />UNIT IV MAY 1 5 2003 <br />ENVIRONMEN F HEALTH <br />PERMIT/SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> <br />, , , <br />WELL Location 44- if) 41)14 F-tiftr---- Cross Street 6-1(6m1 f City 74,49(X Zip ,c5/6 Parcel# 4.sy -64o - .4 <br />PROPERTY Owneri OE re STL je. Address 72'-.Cri- 4. City 77--/467 Zip .57.S---Phonet(20 g3S-c-6,r/5; <br />C-57 Contractor lir /4/62141-7- Address "),: ) Zip f.SIOLic# SI 9 ftionet64iY-7/7cc <br />Consultant / Sub Cntr A Cr- E Address V "3 7 c alt,-..) 4,21.)citySviLic# &e)2.2 7 Phone0c9OVe27-/0 k2 <br />GIS Coordinates: X , Y , Township Range Section <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS TYPE OF WELL <br />MONITORING <br />fl EXTRACTION <br />HOLLOW STEM DIA. OF BOREHOLE <br />[] AIR HAMMER/DRIVEN CASING THICKNESS <br />MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA: <br /> TYPE OF CASING: [] STEEL PVC U OTHER: <br />0 VAPOR [] MUD ROTARY <br />AIR SPARGE / Ozone fl PUSH POINT <br />fl SOIL BORING [] HAND AUGER <br />[] OTHER: 0 OTHER <br /> <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [] AUGERS [] HOSE <br />GROUT SEAL PUMPED: g Yes [] No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br /> <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> <br />*COMMENTS: <br /> <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ojthnnces, Rcul s d Regulations, and all applicable California State Laws. <br />Signed x Title/Company 57-11/Ct4 C776&4"...-/4-(14,6A4'i.v <br />Print Name tAaL r7COrt'. Date O<----- IS - (5 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: c) %-( c' O I Gs-f-C fa_e/ <br />( - e € v_AA4 A-1, /r 2_00 2.. WORK PLAN DATED: 0 ukt) 6-t", f 2o0 "?..... -- p,r (,7( -e tAfj ut ,A__, <br />Date .5 1 2..-3-/C3 Final Inspection By C <br /> I (/' 14' -2) Aect....._ Date 512-7-/00 —2,, <br />Date Issued Area <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAc# <br />._ <br />--1 , /::() :? 3 .._ _..- <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERM- <br />, <br />I- <br />_-- <br />SERVICE REQUEST # INVOICE <br />3O2.. 11,60.00 1c64qcc- ttA cliclo, SR# 33 5g. z--9 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />1/t\astm..Ar <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />Encroachment doc <br /> <br />8/29/02 <br />